Midwives should be key collaborators in integrated health systems

By Angela Freeman, RM, MSc

Arriving in Belfast, Northern Ireland at the end of April, I had just completed an intensive fellowship as an embedded researcher within an Ontario Health Team (OHT). Steeped for ten months within the regional level of Ontario’s health-care reforms, I was ecstatic to be attending the International Conference on Integrated Care (ICIC). Now in its 24th year, this conference attracts more than 1000 international delegates, providing an opportunity for health-care providers, patients and caregivers, leaders and researchers to share insights on implementing integrated care.

Models of integrated care are gaining traction internationally, aiming to improve patient and provider experiences, increase population health, and increase equity and efficiency across the system through improved care coordination—a group of goals also known as the Quintuple Aim. Although definitions vary across settings, the International Foundation on Integrated Care (IFIC) has identified nine pillars of integrated care, which include reducing siloed approaches to care delivery, building alliances based on common visions inclusive of providers and community members, and aligning payment systems to name a few. [i]

In Ontario, OHTs, made up of collaborative partner organizations from across the health sector and beyond, are being modelled after international examples of integrated care. Tasked with providing more streamlined health care within their communities, 58 OHTs have formed since 2019 and are at various stages of development and maturity.

There is incredible value in [midwives'] collective knowledge and experience providing client-centred, personalized care. We understand the system, its gaps, and the experiences of both our clients and our own as providers. We have a growing body of data and research, as well as emerging models and innovative practices that improve quality of care and care access.

During my OHT Impact Fellowship and while attending the conference, I often reflected that many of the values informing the design of integrated care models align well with the midwifery model of care. Afterall, providing equity-driven, person-centered care, while optimizing providers’ scope of practice and interdisciplinary teamwork to deliver timely, evidence-based care, is what midwives have been doing well since regulation, right?  

Yet, after attending multiple presentations addressing the right mix of providers for team-based care, cross-sectoral health human resource challenges and the critical role of primary care providers in governance models and health care decision-making, I was acutely aware of the lack of focus on reproductive health and perinatal care, and the lack of representation by midwives or our care model. I may have been the only midwife there!

Midwives are innovators, leaders and collaborators. There is incredible value in our collective knowledge and experience providing client-centred, personalized care. We understand the system, its gaps, and the experiences of both our clients and our own as providers. We have a growing body of data and research, as well as emerging models and innovative practices that improve quality of care and care access. Midwives are actively engaged in providing streamlined and wraparound care, and yet were not at this table.

In some ways, this observation was not surprising. Prior to the conference, I had been working on a poster presentation exploring what is known about the participation and collaboration of midwives within the OHT partnerships. To get started, with guidance from my academic mentors, we conducted an environmental scan. We found that, despite midwives making up a significant portion of the perinatal care workforce, only 13 of the 97 AOM-listed midwifery practice groups are currently engaged as collaborating partners within OHTs, and less than a quarter of OHTs have midwives or MPGs at their partnership table.

These numbers unfortunately don’t offer insights on the perspectives and experiences of midwives but made us curious to consider why this may be the case. With many OHTs being in their first 1-to-4 years of implementation, in a context of changing government guidance, lots of unknowns remain. Current OHT priorities have also largely mirrored those set by the Ontario government, focusing on streamlining care for older adults, improving access and pathways of care for chronic illness, mental health and primary care. While midwives are primary care providers and likely see the connections between perinatal care and other parts of the health system—or the health of childbearing people and families and the health of the whole population—it may be difficult to know how to engage in the current priorities or find capacity to manage the associated workload.

More exploration is needed on how, or if, midwives are engaging with OHTs in other ways, and how midwives are participating within integrated care models more broadly. By conducting a rapid review of the literature, we learned that the role of midwifery practice groups as collaborators in integrated care leadership and governance has not been explored. We also noticed the articles generated by our search terms focused on midwifery collaboration and integration at multiple levels, with studies describing midwives’ interactions with clients and other providers on the front line, to their integration within organizations and at the level of health systems. We also found that facilitators and challenges for collaborating in integrated care models may be closely entwined with factors impacting the integration of midwifery at all system levels.

There is room at the table for allied health professionals and specialized primary care providers like midwives, and I would argue they are needed there.

So where do we go from here? After recently attending the Association of Ontario Midwives’ (AOM's) Midwifery Sustainability Roundtable at the end of May, it is not lost on me that factors impacting midwives’ integration, many of which affect midwives’ ability to provide client care and their experiences doing so, are also identified as factors impacting the sustainability of the profession.[ii] How then, as a profession that is spread thin with critical concerns about burnout and attrition, do we ensure that midwives and leaders are represented within spaces like health-care conferences, attended by those with decision-making influence?

I don’t have the answers but am reminded frequently that systems change slowly. Integrated care models that balance ground-up direction and priority setting with policy support and system design are still in the early stages; there is lots to learn. There is room at the table for allied health professionals and specialized primary care providers like midwives, and I would argue they are needed there. Accessing the AOM Professional Development Fund made attending the ICIC possible and can increase our collective opportunities for getting to these tables. As midwives are further integrated within health systems, deciding how we want to collaborate with other providers and community members in co-designing locally responsive and driven care models, while maintaining our autonomy and unique model of care, will be increasingly important.

Angela Freeman, RM, MSc (she/her) has over 15 years’ midwifery experience providing care in a large rural practice. In 2020, she completed her master’s degree in Public Health Sciences at the University of Waterloo. Most recently, Angela completed an applied research and evaluation fellowship within an OHT through the University of Toronto. She brings a systems-thinking approach to her research and evaluation work, with interests in patient and provider experiences, early pregnancy care, midwifery integration, collaborative partnerships and rural health care delivery.